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Population Health for Nurses

9.4 Geographical Disparities

Population Health for Nurses9.4 Geographical Disparities

Learning Outcomes

By the end of this section, you should be able to:

  • 9.4.1 Examine how health status and health outcomes vary by geographical location.
  • 9.4.2 Explain how a zip code influences health.
  • 9.4.3 Assess contributing factors leading to geographical disparities.

Throughout history, geography has influenced the health and well-being of communities in various ways. The environment affects the nation’s food supply and plays a role in disease transmission. Geography also affects health care delivery and health outcomes of the population. Geographical disparities refer to the differences in health care access and outcomes based upon where an individual lives. Disparities are often discussed in terms of rural or urban living; however, there can be health disparities between populations of different states.

The U.S. Census Bureau defines urban and rural areas based on population size and density. For an area to be considered urban, it must encompass at least 2,000 housing units or have a population of at least 5,000. Rural areas are considered all population, housing, and territory not included in an urban area (U.S. Census Bureau, 2023). Most counties in the United States have a mix of rural and urban populations (U.S. Department of Agriculture [USDA], 2023). According to the 2020 census, 80 percent of the U.S. population live in urban areas, while 20 percent live in rural areas (U.S. Census Bureau, 2022).

Factors Influencing Population Health Related to Location

The 2022 National Healthcare Quality and Disparities Report compares health care quality and disparities scores on over 100 health-related measures among states (AHRQ, 2022), with the following results:

  • Best overall health care quality: Maine, Massachusetts, New Hampshire, Pennsylvania, Rhode Island, Iowa, Minnesota, North Dakota, Wisconsin, Colorado, and Utah
  • Lowest overall health quality: Alaska, Arizona, California, Montana, Nevada, New Mexico, Wyoming, Washington D.C., Georgia, Mississippi, Oklahoma, Texas, and New York
  • Fewest racial and ethnic disparities overall: Arizona, Hawaii, Idaho, Oregon, Washington, Arkansas, Kentucky, Virginia, West Virginia, Kansas, and New Jersey
  • Most racial and ethnic disparities overall: Connecticut, Massachusetts, New York, Pennsylvania, Illinois, Minnesota, Ohio, Washington D.C., North Carolina, and Texas

There are several reasons for variations among states in terms of health care quality and disparities (AHRQ, 2022). First, health policy can vary by state. Some states may offer more health-related resources or social programs than others. Health care delivery infrastructure can vary by state. For example, some states regulate the construction of new hospitals and other treatment facilities more closely. Finally, disease prevalence can vary by state. For example, diabetes, arthritis, and chronic obstructive pulmonary diseases are more prevalent in eastern U.S. states (Raghupathi & Raghupathi, 2018). Diabetes, in particular, is influenced by cultural, behavioral, and environmental factors associated with certain geographical areas (Zang et al., 2021); it is more prevalent in the southeastern and Appalachian portions of the United States (CDC, 2022a). Asthma is another disease with some geographical trends, although a lot of variation related to population density and demographics can exist in a particular state. The Northeast Mid-Atlantic asthma belt (from Greensboro, North Carolina, to Boston, Massachusetts) has been shown to have a higher prevalence of asthma possibly due to poverty, poor air quality, and less access to specialists (Pate et al., 2021). The Asthma and Allergy Foundation of America (2018) identified a second group of states with an increased prevalence of asthma and associated ED visits and deaths. The Ohio-Lake Erie asthma belt spans from Louisville, Kentucky, to Detroit, Michigan.

Health and related outcomes vary not only by state, but also by county, town, or zip code. Research has linked zip codes to health outcomes (Holmes et al., 2018). For example, people living in neighborhoods with limited access to healthy foods and safe areas to exercise are at higher risk for health problems.

Zip Codes and Life Expectancy

This interactive site What makes a long life? from the Robert Wood Johnson Foundation provides a tool that illustrates the differences between life expectancy based on a person’s address.

Enter a street address or zip code of interest to see how the life expectancy of people living at that location compares to others in the county, state, and nation, and then answer the following questions.

  1. What address or addresses did you enter?
  2. Are the findings consistent with what you expected?
  3. Among the locations you searched, did you discover significant differences among nearby locations? If so, what were they?

Factors Influencing Population Health Related to Population Density

Some of the most common geographical disparities exist between those who live in rural areas and those who live in urban areas. Individuals living in rural areas face geographic isolation, lower socioeconomic status, higher rates of health risk behaviors, limited access to health care specialists and subspecialists, and limited job opportunities (Rural Health Information Hub [RHIH], 2023). Additionally, residents who live in rural areas are less likely to be employed by organizations that provide health insurance coverage. If individuals living in rural areas also live below the poverty level, they are less likely to be covered by Medicaid (RHIH, 2023). Rural health disparities are often caused by access to health care and public health services, socioeconomic status, health behaviors, and health insurance status. Rural Americans are at a greater risk of death from heart disease, cancer, unintentional injury, chronic lower respiratory disease, and stroke than Americans who live in urban areas (RHIH, 2022). Rural residents tend to be older and more obese and to have more health problems than urban residents. They are more likely to smoke cigarettes and are less likely to use seat belts (Figure 9.5) (FDA, 2021). Table 9.3 presents relevant factors affecting rural health outcomes.

An infographic shows a seatbelt about to be clicked into place. There are hearts on the strap and on the buckle. The infographic states: Valentine, we're like a seat belt and buckle… we just click.
Figure 9.5 National efforts to promote the use of seat belts include public information campaigns, such as this valentine-themed graphic from the National Transportation and Safety Board. Studies have shown that residents of rural areas are less likely to wear seat belts than residents of urban areas, which is one factor contributing to higher traffic fatality rates in rural areas (CDC, 2017). (credit: “NTSB Valentine” by National Transportation Safety Board/Flickr, Public Domain)
Factor Discussion
Access to health care and public health services
  • Rural areas tend to have shortages of quality physician offices and other health-related resources. Health care organizations in rural areas have difficulty recruiting health care providers.
  • Limited access to health care providers and services equates to poor health outcomes for individuals.
Socioeconomic status
  • Individuals living in rural areas tend to have higher rates of poverty compared to their urban counterparts. Job opportunities tend to be scarcer in rural areas than in urban areas.
  • High poverty equates to limited health care access, leading to poor health outcomes.
Health insurance status
  • The highest prevalence of uninsured individuals is among those living in rural areas. Higher poverty rates in these areas limit residents’ ability to pay for health insurance coverage. Depending on the policies in the state in which they reside, they may not qualify for Medicaid.
  • Lack of adequate health insurance equates to limited access to care, leading to less-than-optimal health outcomes.
Health behaviors
  • Individuals living in rural areas often have limited access to resources that lead to positive health outcomes. Additionally, these individuals tend not to exhibit other health behaviors such as physical activity, maintaining a healthy body weight, and getting sufficient sleep.
  • Stress and other environmental factors may lead individuals living in rural areas to adopt unhealthy behaviors such as smoking, drug use, or alcohol use.
Table 9.3 Factors Affecting Health Outcomes in Rural Populations (See Rural Health Information Hub, 2023.)

Unfolding Case Study

Part B: Addressing Disparities

Read the scenario, and then answer the questions that follow based on all the case information provided in the chapter thus far. This case study is a follow-up to Case Study Part A.

Marinelle contacts the clients who have missed the most prenatal appointments. These clients report difficulty finding transportation to the appointments. Many clients feel stressed about not having enough money and resources to support their families after their infants are born. One client describes her difficulty trying to find a home closer to town and in better condition than her current home. Marinelle works to find reliable transportation for the clients to help them make it to their appointments. She also arranges for a social worker to visit the clients to discuss their economic concerns.

What should Marinelle consider as a factor influencing clients living in this neighborhood?
  1. Racial discrimination
  2. Residential segregation
  3. Environmental injustice
  4. Gender differences
Which of the following is the best indicator for Marinelle to use to evaluate the effectiveness of her interventions to address maternal health disparities in this population?
  1. Client satisfaction
  2. Provider satisfaction
  3. Rate of pregnancy-related complications
  4. Number of missed appointments

Access to Maternal Health Care in Rural Communities: A Patient’s Personal Story

In this video, a family discusses the barriers to maternal health services they face while living in a rural area.

Watch the video, and then respond to the following questions.

  1. What are some of the specific barriers faced by the family presented in the video?
  2. What is the importance of having access to health care services in rural areas?
  3. What lessons learned from this situation can be applied to other rural health situations?

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